The Emotional Journey of a Keyworker Keychild Relationship – A Therapeutic Case Study

By Claire Cooper

Date Posted: June 14th, 2012

Claire Cooper works at the Mulbery Bush School and is also a graduate of Mulberry Bush Training and this article is adapted from an essay Claire wrote during her training.

The details of the child of described in this article have been altered to assure privacy and anonymity.

The Emotional Journey of a Keyworker Keychild Relationship – A Therapeutic Case Study

At the Mulberry Bush School where I work all children that are placed with us have a keyworker who works alongside the child, holds a higher level of preoccupation of that child’s needs and the work with that child. They have a number of responsibilities surrounding the practicalities of a child’s placement and often, though not always, will develop a well-established relationship with that child and be the adult that the child is closest to.

I keyworked Alfie Smith since he moved to Jigsaw House (one of the residential houses) in November 2008. Alfie was 8 years old at the time and this was his first residential placement. He lived with his mother and two sisters outside of school and had some contact with his father.

At the time to which this case study related I was employed as a Therapeutic Care Worker and keyworking was part of my job description and although I did receive a promotion during this period, it was agreed that I would continue to keywork Alfie until the end of his placement as a change in keyworker was felt to be detrimental to Alfie’s completion of his placement with us. Regardless of my change in position the work involved observing the children and understanding their behaviour as a communication. Workers were expected to use themselves to inform the work by being able to reflect upon their own feelings and the relationships that they experience at the school.

“At the core of this professional task is a commitment by each adult to the conscious use of themselves within the staff group to make sense of and understand the work at all levels and the feelings engendered by it”

(The Mulberry Bush School, 2008)

Aims and Purpose of this case study

To explore and reflect upon the keyworker- keychild relationship, from beginning to end, how it develops and grows and the emotional impact of this relationship using relevant theory and practice experience.

To produce recommendations for training in my own place of work and in similar organisations.

To show my assisting part in a well planned and thought out transition for Alfie.

To support me in processing the difficulties I predicted myself and Alfie would experience as his leaving approached.

To identify and reflect upon how learning has impacted upon my practice and areas for continuing practice development.

Limitations of my article

This is case study is based on one keyworker- keychild relationship, largely based on my experience and interpretation so it could perhaps be viewed as one dimensional, however I feel this reflects my working experience to date and mirrors the isolation that can be experienced within this relationship.

The original study upon which this article is based study was written during the last 6 months of Alfie’s placement and although the impact of his leaving is a crucial part of the study and one of the aims of my learning, reflection and writing was to support me processing this, it may be that my reflections will be very different at a later date when I have had more time to reflect and process more raw feelings.

Developing the Relationship, how it is built and why it is important

Alfie’s pre placement assessment report stated

“…used to his life revolving around traumatic events and difficulty. One of the challenges we will face in our work with him is to help him redefine himself in a positive way, to support him to build a positive sense of himself as someone who can learn and achieve and does not have to rely on trauma to define who he is and how he creates/relates to friends. He will need support to help him move away from dependant relationships that have trauma and difficulty as their foundation…” (Turberville, 2008)

Alfie’s early life experiences of a violent relationship between his mother and father and then their separation had left him expecting trauma to define relationships and to some extent him. His mother also had a history of drug and alcohol abuse and at the time had and was still suffering from depression which resulted in her being emotionally unavailable at times and possibly physically unavailable as well. The emotional neglect Alfie had suffered had left him unable to form healthy and mutually trusting relationships with adults and children.

Alfie initially presented as a little ball of fury who would unpredictably fly into a rage where he would verbally and physically attack those around him. He had been described as emotionally of an age similar to that of a three year old however reflecting on this I felt that often his emotional ability was closer to that of a new born child and that he was projecting his anger, fear and anxieties into me and other staff. It was therefore paramount that we could provide Alfie with a sense of containment in relation to Bion’s work on containment.

“it is through the process of containment that the infant’s most unmanageable feelings and deepest anxieties are ‘projected’ into the parent so that, initially at least, the parent can feel them for him or her, before handing them back in a more manageable form.” (Ward, 1998, p.15)

Attachment theory informs us that infants will instinctively attach to their carers due to a need for safety, security and protection, ultimately for survival, the strength of this attachment and how healthy it is depends on the responses the child receives (Prior & Glaser, 2006, p.15). Alfie’s early experiences had left him with what can broadly be described as an attachment disorder, which left him with a number of defences against forming other attachments. It was important that I could show Alfie that I could survive these defences, survive him, and that I was going to remain consistent in my responses to him and that I remained physically and emotionally available to him but also given the nature of the Mulberry Bush School that the Organisation as a whole was also able to do this.

Holding Alfie in mind was one of the crucial foundations for our relationship along with getting the practical things right for him such as making sure he had the right clothes, I knew what foods he liked and disliked, what he enjoyed doing, who were the important people in his life outside of the school and also beginning to build relationships with these significant people to give him a sense of everyone working together for him.

I and the organisation as a whole needed to become a ‘secure base’ for Alfie providing him with “…consistency, reliability, responsiveness, non-possessive-warmth, firm boundaries” (Holmes, 2001, p.4).

I recall feeling quite overwhelmed at the enormity of the task with Alfie. Here was this 8 year old boy who often appeared to express emotions of anger and frustration and this often at those who were trying to help. I remember him falling over and grazing his knee and me trying to scoop him up physically to care for him and him physically attacking me. I felt huge frustration. Why didn’t he grasp I was trying to help ? How can I check he is ok if he won’t let me near him? I feel this was symbolic of how difficult it was going to be to emotionally ‘scoop’ Alfie up and help him ; how difficult it was going to be to become emotionally ‘close’. I threw myself into the practical aspects of keyworking drawing on my strengths of communication, organisation and efficiency. All the paper work was up to date, appointments well organised, things Alfie chose for his room quickly presented to him, his weekly challenge always displayed and him reminded of it on a regular basis and so on. I’m not sure if it wasn’t possible at this time or if I wasn’t able to ‘hold’ it all but I don’t recall being particularly in touch with the emotional aspects of Alfie. However over time Alfie began to trust me, even if this was only in a practical sense that I was becoming consistent, reliable and responsive. He began to show me real warmth and affection, greeting me with hugs and a big smile and I guess he was beginning to trust I could ‘hold’ him emotionally as well. He became quite possessive of me and protective referring to me as “his keyworker” and telling other children to “leave my keyworker alone.” I began to think about how this was perhaps replicating the relationship he had with his mother, needing to defend her perhaps and share her and it may also have replicated the relationship he had with his sisters which was largely based on jealousy and was competitive in terms of how they would fight (sometimes literally) for their mother’s attention. I was also keyworking another child at the time a boy slightly older than Alfie and the decision was made for these boys to share a bedroom. I was reluctant at first not wanting to replicate a sibling relationship but also aware of my feeling a greater need to give Alfie more of myself than I perhaps was to the other boy. Them sharing I feel proved one of the most beneficial developments in my relationship with Alfie. He was able to experience sharing me very closely with another child and work through what were difficulties in their relationship around jealousy and it provided him with a lived experience that he could be ‘held in mind’ along with others. At this point his mother also reported a huge shift in the way that Alfie was when he was at home, particularly with his sisters. However this then led to Alfie directing a lot of anger towards his mother, particularly during his phone calls home when he was at school. I was aware I was perhaps becoming this ‘good mother’ and he was beginning to view his mother in a negative way which was causing him some great pain and confusion. If I’m completely honest there was a part of me that enjoyed being this good object and I felt glad that he was cross with his mother because a part of me felt cross that she had managed to not get it right with this child that had such potential to be this amazing, thriving, happy boy. Alfie was beginning to absorb all that the Mulberry Bush had to offer and as positive as this was it was also difficult to imagine how different things could have been for him if circumstance had been different.

How the Relationship grew , how Alfie grew and the emotional impact

Before I explore the relationship that had developed with Alfie and continue with its development I want to draw attention to the progress in Alfie that we had seen by this point which roughly is the first year of his placement. Although we had seen an increase in aggressive incidents from an average of 4.06 per week in the Autumn 2008 term to 5.05 in Autumn 2009 the number of restraints had decreased from 3.8 to 0.8 showing huge progress in Alfie’s ability to ‘contain’ himself to some extent and use the help available to him in order to calm. Academically Alfie was also making progress in all areas (see appendix 1 for more detail).

It’s probably quite fitting to mention that at the stage I was currently at in terms with my relationship with Alfie and the timings of this, now coincided with me beginning the Foundation degree in Therapeutic Work with Children and Young People. I feel that at the time of starting the course I needed to reflect upon the ‘appropriate emotional distance regulation’ I had with Alfie.

“This requires staff members to be supported to ‘inhabit’ a ‘boundary position’ in their minds from which they can interact in the inter- subjective relationship, and yet observe in order to develop a hypothesis about which aspects of the child’s functioning (or lack of functioning) needs to be supported or treated. This distance regulation does not mean the worker withdrawing from the child; rather, it means creating and appropriate thinking space. Our aim is that this work enacts the theory of emotional containment (Bion, 1962) whereby the primary carer receives the ‘transmission’ of impulsive feeling from the child and, through digestion and reflection on this impulse as a communication, they can offer a thoughtful response to meet desired need and facilitate emotional growth.” (Diamond, 2009, p.224)

I began to develop my ability to reflect individually and with my team I was able to recognise, without being defensive which I had previously been, that my relationship with Alfie needed considering. I had almost developed a point of isolation whereby I almost kept him to myself and didn’t share him out, I refer to an emotional state not physical. I had developed a huge desire to put right all the wrongs in his life, fill in all the gaps for him and was increasingly feeling like I was the only person that could provide him with something good. I recall feeling frustrated with others in the team if I came in and heard about an incident he had had and thinking that it wouldn’t have happened if I had been on shift. Sharing and reflecting these feelings with the team and individually allowed me to adjust my position of distance. Recognising and naming these feelings meant that I was able to create the appropriate thinking space I needed in order to provide Alfie with emotional containment. The shift in my ability to think reflectively mirrored a shift in Alfie’s ability to think about his feelings, express them more appropriately and piece together his relationships. As a treatment team we targeted developing Alfie’s social skills, his emotional vocabulary and to develop his understanding of genuine friendships.

Again statistically we saw progress in Alfie. Aggressive incidents decreased from an average of 5.05 per week to 3.21 and anti social incidents also decreased from 3.31 to 1.93. there was a small increase in restraint from 0.8 to 1 but this still indicates massive progress compared to early in his placement when this figure was 3.8.

I felt a huge sense of pride, not only towards Alfie but myself and the work of the team. Alfie was now at a stage where we were targeting developing his emotional resilience; continuing to think about his life at home and now he was going into his final year, making sure the ending was well planned and supported so as it was not a ‘traumatic’ experience for him. Alfie and I had both separately, though I’m sure counter transference was at play, begun to think about his leaving. I am sure as a result of my development to reflect I was able to share very early on how overwhelmed I thought both myself and Alfie may be if his leaving was not processed early on.

Going into his final year Alfie had moved on and grown from a boy that was often in despair to someone that seemed to have a sense of recognition that although certain things were wrong with his life, in particular his mother’s ability to care for him that there was hope. After a difficult holiday home (not with Alfie but one of his sisters) Alfie was sat talking to me about what had happened at home, something he was incapable of doing when he began his placement, but even more impressive in a calm way he was able to tell me he was angry with his mum and said that she needed lessons. I was struck by his ability to recognise faults in his mother and an appropriate feeling of anger but in a contained way, this wasn’t traumatic anymore and he was also hopeful that things would improve, that mum could get better with support and help.

Alfie’s second year felt like very much a journey of emotional development, not just for Alfie but for me too. I would like to think that my ‘growth’ allowed him to ‘grow’ as well. I was and remain taken aback by how strong your feelings towards a child you keywork can become.

The final year, Regression, Transition and saying goodbye

“Traumatized children are likely to have experienced difficult endings and leavings. Trauma disrupts the sense of self. Rather than experiences having a beginning, middle and end, the trauma disrupts the ending or becomes the end.” (Tomlinson, 2004, p.147)

The above is exactly what we wanted to avoid with Alfie’s ending at the Mulberry Bush. Given his early traumatic experiences, and all the progress he had made during his time here it was crucial that the ending is positive. I had huge anxieties about Alfie leaving and how he and I were going to manage the separation. I had imagined his leaving day and him driving off down the lane in his taxi with me running after it in a complete emotional state feeling like he was being ripped away or that he wouldn’t leave without him having to be prised off of me. These were my greatest fears that saying goodbye was going to be so painful for him, me and to some extent the team and school, that all the work around it would be avoided and therefore it would become traumatic for all involved.

“…the importance of adults involved with children in the care system recognising that separation involves fear, which needs to be mastered, and that loss involves grief, which needs to be expressed. Simultaneously with the child’s grief, the person whom the child is separated will be coping with their emotions and will need support as well.” (Fahlberg, 1991, p.133)

As early as November 2010 Alfie, having a well planned and supported ending to his placement, was identified as a target. The process was: adults to begin being preoccupied with Alfie’s leaving and engage in conversations with Alfie if he brings leaving up; Alfie’s next placement to be identified and a clear handover of Alfie to be prepared; A thorough and planned transition to be provided; adults to begin thinking about how they will say goodbye and the emotional impact this may have on them and Alfie.

Soon after I presented in a reflective seminar my fears around the difficulties I may have in saying goodbye and also raised the question around my ‘appropriate emotional distance regulation’ and whether people in my team felt that I was managing this. Alfie’s leaving had been on my mind for some time before this and I felt I was quite clear about what I was going to say. Within a few sentences I became completely overwhelmed almost overwhelmed with grief, I was in tears and struggled to speak. I was able to compose myself and continue. I sat looking at my team after I had finished and they seemed to be a mixture of sadness and shock amongst them. Historically I had struggled to share my difficulties with the team and they often viewed me as very contained and containing so I think to see me be so ‘uncontained’ in sharing my concerns was quite an experience for them and me. Their responses were positive in terms of my emotional distance and no one raised a concern as they seemed to be in agreement that my being in touch with this was evidence enough that I was able to maintain a clear thinking space. Thoughts were offered about how Alfie was coping and it was suggested that he may be holding it together because I am falling apart and the importance for them to support me to be together to allow him the space to fall apart. I found after that the sharing of my feelings had helped me move forward in almost a grieving process and it all began to feel much more manageable.

Regression to early placement behaviours is often experienced when children are leaving and we fully predicted that we would see a regression in Alfie and wanted to try hard to manage this, allowing for some regression but not lowering our expectations of him. We did see a slight regression in the frequency of him needing restraint, to be physically ‘held’ in Spring 2011 increasing from 1.0 in Autumn 2010 to 1.08. However entering his final term at the school he was averaging 2.28 aggressive incidents per week, 0.71 anti social incidents and 0.71 physical restraints. This showed over a 50% reduction in his aggressive incidents over a 75% reduction in the number of restraints and just under a 75% reduction in the number of anti social incidents now compared to when he started at the school. I truly believe that this is a direct result of his final year being carefully thought about and his transition process beginning.

Alfie’s next placement had been identified by March 2011 with Alfie having already visited with his mother, family team worker and me. In May we had a planning meeting with his next placement and the importance of some more pre-placement visits were identified.

“Preplacement visits can: Diminish fears and worries of the unknown; be used to transfer attachments; initiate the grieving process; empower new carers; encourage making commitments for the future.” (Fahlberg, 1991, p.170)

Alfie visited his next placement accompanied by me early in June, with me spending some time with him in the morning and then leaving him in the afternoon and collecting him at the end of school. This visit went very well for Alfie, in fact there was almost a pang of disappointment that it went so well and left me feeling slightly hurt that he was so settled there and that he didn’t seem at all phased when I left him by himself, though this was mixed with relief that the transition process was going as planned. In late June I took him to stay for two nights and then he travelled from there to home for a weekend home before returning to us on the Tuesday. Alfie was very anxious about this visit. The enormity of staying for two nights in what was still a new place was very live for him. When we got there Alfie immediately told me he wasn’t staying and refused to go into the classroom to begin with. I went in and he did follow after some time. To encourage him to stay I promised I would go and then be back in a couple of hours. This was a tactic suggested by his new teacher but I felt uncomfortable about it. For me it seemed almost as if his new placment was in a sense avoiding me saying goodbye perhaps for fear of them being left with the unknown (in Alfie). I called the Mulberry Bush for advice and my line manager and another household manager agreed with my thoughts that I just needed to go and it was likened to a mother and child on the first day of school. I returned to his new placement and explained this to their family support worker and she also agreed. I told Alfie I was going now and that I trusted the adults there to look after him and that I would look forward to hearing about it all after the weekend when he returned to Mulberry Bush. Alfie immediately fell apart screaming and crying, begging me to not leave him. I continued to walk to the vehicle, get in it and drive off with him running after it still screaming and crying for me to stop. As I got further away I looked in the rear view mirror and I watched him fall to the floor. I had tears, but was shocked by how in control I was. I carried on driving knowing that this was a huge step in the transition for him and me.

Alfie survived the overnight visit and so did I. He returned to Mulberry Bush with lots of exciting tales of his time there. We were now counting down the final 12 days that he had left at the Mulberry Bush. He engaged well in his leaving calender which was run for the last 2 months and it included him doing activities with people that had been significant to him whilst at the school.

There were tears when I first wrote this case study all of which I am sure have helped me and Alfie manage his leaving. How will be in 12 days time? My hope is that we can say goodbye, be appropriately sad but also happy and proud of all that has been achieved.

Conclusion and recommendations

Something that became clear to me when first writing this is the need for a greater level of training surrounding relationships that develop with the children in these settings. The Foundation degree has been of huge benefit to my learning and understanding however I had been keyworking children for 2 years before I started this. I would recommend that more consideration be given to the emotional impact of this relationship during induction training as my experience was that this was very much centred on the practicalities and offered very little insight into the emotional impact. I also feel there is a need to explore different relationships. How, for instance would I have felt/managed keyworking a child I really didn’t like for 3 years?

Writing the case study helped me to process and reflect upon my relationship with Alfie and the emotional journey we were on from beginning to end. I would like to explore this further in relation to how I feel once Alfie has left and some time has passed but also would like to compare this to other people’s experiences of keyworking and their relationships.

The learning I did throughout this case study and throughuot the Foundation degree course has helped me to reflect upon my practice and it impacted positively on my relationship and direct practice with Alfie.